Recipe for Building a Medical Home

One Practice Teams' Story on Quality Improvements around Medical Home: Achievements and Insights Presentation

• Summary of Achievements
• Who We Are
• Essential Components for Medical Hom e
• Real Accomplishments
• How Did You Do That?? Detailed descriptions of Implementation
• Resources: Clinical and Financial

Summary of Achievements and Insights

• Almost 600 Children with Special Health Care Needs (CSHCN) identified in registry and in Medical Manager with complexity scores
• Care Coordinator does Pre-visit Contacts for 11 docs; from 3 hrs./wk to full-time
• 93 % of Families find pre-visit contacts helpful
• Printing 3rd ed. CSHCN pocket phonebook; 3rd edition of transition referral options
• Year 3 of tracking improved patterns of Emergency Department (ED) and after-hours utilization
• Boardmaker used for communication-impaired CSHCN
• Planning for Statewide Medical Home Learning Collaborative for CSHCN
• Docs re-educated on coding for CSHCN
• Title V 3 year grant on MH Implementation
• Creating pilot project with Blue Cross/Blue Shield (BCBS) around metrics for Medical Home measurement
• Held forum with our practice, Parents and School Admin. around partnering for CSHCN in schools
• Held “Listening Session” with our practice's parents to identify needs
• Streamlined “checkout” process
• Joining NC Medicaid Managed Care Network
• Computer Access to Duke/University North Carolina

Who We Are

• Our Practice: Chapel Hill Pediatrics and Adolescents, PA (CHPA)
• Suburban private practice with 2 offices in Chapel Hill and Durham, NC
• 11 Pediatricians, 4 full-time, 7 part-time; 6 F.T.E.
• Duke University and University of North Carolina Medical Centers within 15 miles; > 30 year collaboration with both centers
• 85% Managed Care
• 7.45% Private Pay
• 7.1% Medicaid + SCHIP; just joined new Medicaid Network in our 4 county area
• Office hours 365 days a year; extended office hours M-F until 7 pm
• Care for children/youth from birth to age 21
• Do not presently have an Electronic Medical Record (EMR); heading toward EMR

Essential Components for Medical Home
The Beginning: Focus on Medical Home efforts began in April 2003, as we began participation in the NICHQ Medical Home Learning Collaborative for CSHCN that used the Model for Improvement (tests of change on a small scale, with evaluation and revision to direct expansion of change) to initiate and sustain changes in care delivery

We have identified 6 essential components to implementation of Medical Home concepts as defined by AAP Policy Statement

1. Relationships
   • Collaborative relationships between parent/child/CHPA
   • Enhanced connections between CHPA/community
   • Collaboration between Primary/Specialty MD’s/Training Programs
   • Interaction between MD’s/Insurers
   • Dialogue between MD’s/State of NC on care for CSHCN statewide
   • Interface between MD’s/Policy makers to underscore clinical need for Medical Homes for all children, but especially CSHCN
2. Ready Access
   • ADA approved entries, exam rooms, bathrooms
   • Offices on local bus lines
   • Handicapped parking slots at door
   • Office hours in evenings, Saturdays, Sundays, holidays
   • Advice nurses both day and night
   • On-call provider 24/7, 365
   • Same day appointments reliably available
3. Care coordination to provide assistance with referrals, preparations for visits, communication with specialists, assistance with support services
   • Registry
   • Identification of CSHCN, defined by CAHMI screener
   • Gradual registration by MD/staff recall, computer review by diagnosis, identification in process of care.
   • Identification of CSHCN gives mechanism for proper scheduling/coding, recall by diagnosis for services like Synagis/flu shots
   • Working data base for care coordination services
4. Resources
• Identified clinical providers for all sorts of services (lactation, domestic violence, psychiatry, dentistry, PT, etc), with data available for use in the process of clinical care
• Identification of clinical and policy-making individuals at Medical Centers for referrals and advocacy
• Location of funding sources for clinical services (example: Project FAST at the Arc for un-funded care items like wheelchair ramps)
• Identification of high-quality Parent Support Links
• Establishment of technological resources (such as computer links with Duke/UNC for information exchange around clinical care)
• Development of constructive linkages with insurers
5. Reimbursement
   • Federal/State Policy level discussions with ALL insurers to address costs of care for growing numbers of CSHCN.
   • Ongoing evaluation of the practice’s coding procedures, with data collection for insurer contract negotiation
   • Formal, annual contract renegotiations with insurers
   • CSHCN coding education for providers, with coding reviews to educate on missed charges, inadequate documentation
   • Documentation of cost-saving features of Medical Home; decreased ED utilization, decreased “downstream utilization” such as hospitalization
   • Development of incentives for practices making Medical Home quality improvement efforts (“pay for performance”)
   • Funding to continue clinical services (care coordination work, data collection, clinical education, parent links)
   • Recognition/documentation of/payment for: telephone calls,
     care coordination, advice lines, after hours services, records review and form completion
6. Recruitment
   • Identification of Practices with “inclination” to be Medical Homes
   • “Tool Kits” of forms, directories
   • “Spoon-feeding” (clinical education, coding, parent support systems) to encourage other practices to embrace Medical Home features
   • Recognition of those providers by AAP, Medical Centers and insurers
   • Evidence that provision of Medical Home services can be financially viable for the clinician/practice

REAL ACCOMPLISHMENTS in areas of Essential Components
1. RELATIONSHIPS

• Boardmaker used for communication-impaired CSHCN
• 93 % of Families find pre-visit contacts helpful
• Stronger collaboration with NC Title V through grant/quarterly meetings
• Established working group with BCBS senior medical directors
• Computer Access to Duke/UNC.
• Joined NC Medicaid Managed Care Network
• Held “Listening Session” with CHPA parents to identify potential areas of practice improvement

2. READY ACCESS

• Streamlined “checkout” process
• Care Coordinators with direct phone lines

3. REGISTRY

• Over 600 CSHCN identified in registry and in our Medical Manager, with complexity scores
• Registry used for pt. recall for flu shots, Synagis, and local support group on autism

4. RESOURCES

• Care Coordinator does Pre-visit Contacts for 11 docs; from 3 hrs./wk to full-time.
• Care Coordinators assist with referrals to specialists, assuring pertinent records are sent
• Printing 3rd ed. CSHCN pocket phonebook; 3rd edition of transition referral options
• Held forum with CHPA, Parents and School Admin. around partnering for CSHCN in schools.
• Title V 3 year grant on MH Implementation.

5. REIMBURSEMENT

• Year 3 of tracking improved patterns of ED and after -hours utilization
• Docs re-educated on coding for CSHCN
• Considering pilot project with BCBS around metrics for Medical Home measurement/pay for performance

6. RECRUITMENT

• By referral from Title V, have assisted other practices in details of registry development
• Presented “what we’ve learned” at Medical Home Learning Collaborative 2
• Contributed the pre-visit contact protocol to Maternal Child Health Bureau’s “Promising Approaches” document on interfacing primary and specialty Pediatric care.
• Will be presenting work on registry at North Carolina Healthcare Information and Communications Alliance (NCHICA) in 5-06

How Did You Do That?? Detailed descriptions of Implementation
Ready Access through Development of Care Coordination Position (pre-visit contacts, and assistance with referrals, capture of episodic care).

1. Began Care Coordination 1-3 hours week, doing pre-visit contacts, funded by BCBS Foundation Grant. Initial care coordinator was lab director, who added 1-3 hrs./wk
2. Developed a Pre-visit Contact form
3. Starting with 3 MD’s, Care coordinator (CC) identified CSHCN coming for checkups in next 2 weeks. MD’s who registered their CSHCN first were first to receive pre-visit contacts.
4. Using pre-visit contact form, CC made pre-visit contact phone calls to parents of CSHCN with upcoming physicals.
5. CC assembled all consults, lab results, ED records since child’s prior checkup, identified parent concerns, and arranged for EMLA cream if labs to be drawn.
6. CC assures that adequate time has been scheduled for visit.
7. CC gives chart and data to child’s MD for data review
8. Pre-visit contacts is entered in chart with physical form
9. CC attaches Parent Survey form to chart for parent response on pre-visit contact value

Referrals

1. Educated staff member who had previously assisted with referrals to focus on CSHCN. Parents were directed to that staff member for assistance with referrals, test scheduling
2. Referrals staff began recording all referrals to assure follow up if needed
3. Referrals began to develop data base of contacts in both Medical Centers and the community for referrals. Added fax numbers to data base for communication
4. Parents began to access referrals directly for problem solving around appointments
5. CC assists referrals around more clinical issues/questions

“Capture” of children who appear only for episodic care

1. Recognized that many children with chronic conditions utilize
   regular and after-hours visits for “crisis management” and do not
   have regular physicals, chronic condition management visits
2. MD seeing patient notes lack of checkups, delayed immunizations, lack of
   Asthma plan, etc. and gives child’s name, birth date and chart number to
   CC.
3. CC notifies parent to make appointment for physical and does pre-visit contacts.
4. CC enters child in registry and office computer.
5. CC identifies obstacles to regular care ( transportation, parent work hours, lack of insurance?) and works to address obstacles.

Registry development (from no registry to over 600 kids with SHCN)

1. Registry includes: Name, birth date, chart number, primary MD, insurer, major diagnoses, and identification in Medical Manager as “Special”
2. Paper survey to all docs to recall their CSHCN (most complex children, children whose visits always take more time, CSHCN who are technologically dependent, children in group homes or residential care). Recall improved by listing diagnoses such as Down Syndrome, seizure disorder, cerebral palsy, bipolar disorder, congenital heart disease, autism, childhood malignancy, etc. to prompt recall
3. Computer recall by Diagnosis (pre maturity, asthma, etc.) from office admin. system (ours is Medical Manager)
4. Initially tried internet based software Docsite as part of Medical Home Learning Collaborative. Found it to be unwieldy and expensive, so went to paper and Excel; presently looking at Filemaker and awaiting EMR
5. Gave incentive for MD’s/staff to identify/register by beginning pre-visit contacts. Pre-visit contacts prompt preparation for CSHCN’s checkups, encourage proper time scheduling, and identify parent concerns/need for pain control prior to exam
   (see Recipe #2 for more on pre-visit contacts)
6. Assigned complexity scores as “ticket” for pre-visit contacts
7. Began with only 3 MD’s receiving pre-visit contacts, and gradually increased to serve all 11 MD’s
8. Parent survey of value of pre-visit contact document that 93% of our parents find pre-visit contacts“very helpful”. Initial survey was mailed to parents who had had pre-visit contacts in past year, then revised to be given to parents right after visit. Parents prefer the immediate opportunity to give feedback.
9. Registry data permits “tracking” of ED utilization, after-hours visits, and subspecialty visits for those CSHCN insured with BCBS (our primary payor)
10. Registry data used for recall for Synagis, flu shots, and diagnosis-based educational sessions (autism)
11. Registry data used to invite parents to educational forum and listening session
12. Registry data encourages proper time scheduling for appointment making care more efficient and decreasing wait times.
13. Registry permits advance identification of children needing Boardmaker for communication assistance at clinical visit

Resources, clinical and financial
Identifying Clinical Resources for CSHCN

1. While both Duke and UNC have formal phonebooks of their specialists, we recognized that many of the community providers/services we used were unidentified and required leaving the exam room or a call-back to give the parent referral information
   
   
2. Sent survey to all MD’s, asking for the specialists to whom they often referred/preferred in the following areas:
   
   

   Audiology	Developmental Evaluations	OT/Feeding/Oral Motor
   Augmented Communication Assistive Technology	Developmental Therapists	Podiatry
   Autism	Eating Disorders	PT
   Child Abuse	Gynecology, Adolescent	Rehab.Specialists
   Child Psychiatry/Psychology	Lactation Services	Speech
   Community Physicians	Nutrition	Substance Abuse
   Dentistry for Children	Orthotics

   
   Promise of a copy of the directory for those MD’s who responded was incentive
   to participate.
   
   
3. Dr. Lail, with help from Title V and parents, collected contact data for service
   providers in other areas, including:
   
   

   NC State Programs for CSHCN	Health Departments for 4 surrounding counties	Social Services
   Baby Nurses	Home Health Care/Equipment	Social Security
   Car seats for CSHCN	Parent to Parent Connections	Travel for CSHCN
   Early Intervention contacts for 4 surrounding counties	Rare Disorders	Vocational Rehab.
   G-Tube and Trach care contacts at Med Centers	Recreation for CSHCN	We also added numbers for local hospitals, ERs at all hospitals, Poison Control and Rabies Control, as well as CAP programs, and the State Special Needs Hotline. Special notations, such as “takes Medicaid” or “only sees adolescents” are in margin.
   Grief Counseling/Hospice	Respite/Residential Care for CSHCN
   Group Homes for CSHCN	School Systems

   
   
4. This directory, was printed in a pocket-sized, 4X6 inch format, coil bound to fit in
   doctor’s pocket for access while in process of care.
   
   
5. Empty pages were left in the back for changes/additions.
   
   
6. Book was used by MD’s, nurses, CC as an INTERNAL DOCUMENT. Book is not circulated to parents.
   
   
7. Directory gradually used by all MD’s
   
   
8. After 1 year in use, directory updated. MD’s requested to send in the changes they’d made thru the year. Staff called numbers of less frequently used providers to assure accuracy, and book reprinted with additions/corrections
   
   
9. After second year in use, same process used to print 3rd edition. All MD’s now
   routinely dependent on the phonebook, and CC is working on maintaining computer data base of resources for her clinical encounters with patients.
   
   
10. Initial funding for phonebook thru BCBS Foundation, and subsequently through
    Title V Medical Home Grant.

Identifying Financial Resources for Quality Improvements:

1. To obtain funding for CHPA to participate in NICHQ’s Medical Home Learning Collaborative (MHLC) , Dr. Lail solicited support from BCBS Foundation. Division of Medical Assistance matched funds to permit attendance in collaborative and pilot of care coordination, registry development and resource identification.
   
   
2. Title V had partial participation in the M HLC, and subsequently offered funding with a grant to continue quality improvements after MHLC completed.

Reimbursement

We have worked on reimbursement for our Medical Home interventions in six arenas.

1. Proper coding for work done, and MD education for proper coding.
2. Charge capture
3. Documentation of the financial value of Medical Home services, particularly to insurers
4. Aggressive approach to insurers for contract renegotiations.
5. Funding from external sources, such as BCBS Foundation and NC Title V grants.
6. Increasing MD efficiency with resources while in the process of care and care- coordination to permit maximal MD time in revenue producing activities.

Proper Coding for Work Done

1. Our billing personnel (trained in coding) reviewed 6 CSHCN charts from each physician to evaluate adequacy of coding, with feedback about missed charges and under-coding. This review clarified that MD’s needed more coding education.
2. Practice engaged coding educator, and continues to track MD coding practices. Particular attention to the use of modifiers for complex well-child care proved valuable.
3. Practice changed checkout procedure so co pays were collected prior to visit, permitting MD to retain billing sheet until he/she had time to do more careful billing
4. Our MD “culture” had a long history of under-coding—partially due to lack of coding education, but also due to the “we are nice guys” mentality and the knowledge that parents are young people and health care is expensive. With our large Managed Care population, over 80% of our families paid only a co pay—no matter how extensive or lengthy their care was. Clarifying this point seemed to help MD’s understand that they must charge for what they do.
5. Using the registry to help schedule longer appointments for CSHCN has permitted MD’s to spend effective time with CSHCN and charge for the time expended. Some of our under-coding culture arose from the fact that the MD’s felt they had not fully addressed this complex patients’ needs, and so under-coded for the visit.
   6) Proper time scheduling for CSHCN decreases the likelihood of long office waits because the “doctor is running behind”. Some of our docs were apologetically under-coding because a patient had had to wait for them.

Charge Capture

1. MD’s and staff were reminded (again) to charge for all services provided. Hearing and vision screens for PE’s, oral medications given, pulse oximetry and cerumen removal are examples of items often not registered as charges.
2. Rerouting the billing sheets to permit MD’s to carefully enter the proper charge and services provided (see #3 under proper coding)

Documentation of Medical Home value to insurers

1. We did a cost benefit analysis of our after hours services, annotating our costs to provide services in our office on weekends, weeknights and holidays. Documenting the cost of these services to insurers underscores the money saved in visits diverted from the ED.
2. With help from our registry, we collaborated with BCBS to evaluate ED utilization, after hours visits, and specialty visits for our BCBS members in our CSHCN registry, and also for a subset of CSHCN with what insurers call “high-maintenance” diagnoses. (see listed on BCBS document). The comparison group was other Triangle area Pediatric practices.
3. BCBS data showed a statistically significant difference in ED utilization for our CSHCN which was sustained over the 3 years of Medical Home interventions. BCBS data documented increased after-hours utilization and slightly higher specialty utilization for our CSHCN. However, most recent data suggests a decrease in subspecialty visits for our CSHCN over the period of time of Medical Home Quality Improvements ( which may be related to care coordination and closer collaboration with their Medical Home.)
4. Preliminary data from CHPA records suggests that our CSHCN are not our highest utilizers of extended care hours. This data collection continues.

Aggressive contract renegotiations

1. CHPA engaged a professional to assist with contract renegotiation with our 6
   major insurers. Her expertise plus documentation of our Medical Home efforts resulted in favorable increases in all our reimbursement contracts.

Other Funding Sources

1. BCBS Foundation was willing to fund part of our participation fee for the Medical Home Learning Collaborative and improvements related to the collaborative.
2. Work with Title V through the Medical Home Learning Collaborative has resulted in a three-year Medical Home for CSHCN quality improvement grant.

Increasing MD efficiency

1. Our pocket clinical directory, list of doctors for transition to adult care, and computer connections with both Duke and UNC Medical Centers have streamlined clinical efficiency, permitting more time in reimbursable activities. See Recipe # 3 above for details about clinical directory.
2. Care Coordination makes dramatic increase in efficiency. See Recipe #2 for details on the evolution of Care Coordination

Last Updated March 19, 2007